2 The NHS complaints system |
Overview of the NHS complaints
5. It is not the Committee's intention to give a
comprehensive history of the NHS complaints system, as this can
be found elsewhere.
The Committee notes however that the first comprehensive complaints
system for the NHS was introduced in 1996, replacing a highly
fragmented system where NHS organisations had their own approaches
to complaints handling. Since then, the complaints system has
largely maintained and built upon the core principles that complaints
should, where possible, be resolved by the organisation concerned
to enable speedy investigation, organisational learning and resolution
to the satisfaction of the complainant.
6. Where complaints are not resolved locally, independent
review of a complaint has also been available for some time, albeit
in a number of different guises. In 2003 the independent review
stage was handed to the predecessor body of the Healthcare Commission.
Throughout these changes, the role of the Health Services Commissioner
(or the Health Service Ombudsman as it has become known) has continued
to provide the final stage of the complaints system. Where complainants
failed to achieve resolution either locally or through independent
review, the Ombudsman has, within certain parameters, offered
another opportunity to investigate and resolve complaints.
7. In addition to the complaints system, further
reforms were proposed following a number of inquiries into failings
in the NHS. Most notable of these were the Neale Inquiry
(set up following the poor standards of care delivered by former
gynaecologist Richard Neale) and the Ayling Inquiry
(following the conviction in 2000 of former GP Clifford Ayling
on 12 counts of indecent assault). These inquiries directly led
to the establishment by the Department of Health of Patient Advice
and Liaison Services (PALS) and Independent Complaints Advocacy
Services (ICAS), both of which will be considered in more detail
later in this report.
8. The complaints process is underpinned by statutory
instruments and by the NHS Constitution. The Constitution guarantees
that patients have the right to a proper investigation of their
complaint, to know the outcome of this, to take their complaint
to the Health Service Ombudsman should they not be satisfied,
to make a claim for a judicial review if they have been unlawfully
dealt with and to be compensated for any harm done.
9. In her 2005 review of the NHS complaints system,
the Ombudsman found that a number of actions were required in
order to improve complaints handling in the NHS. These included
the establishment of a clear set of national standards to be adhered
to by all providers of NHS care and treatment, the requirement
for regulators to ensure that providers are meeting these core
standards, the integration of the health and social care complaints
systems and the development of alternatives to in-practice resolution
of complaints about GPs.
10. The current NHS complaints system was created
in 2009 and is, to a degree, based on the Ombudsman's recommendations.
Patient Advice and Liaison Services were retained in order to
offer immediate advice to complainants and to support early resolution
of complaints, and Independent Complaints Advocacy Services were
also retained to offer information, advocacy and support. A simplified
two-stage process was created, and the intermediate stage of the
process (independent review by the Healthcare Commission) was
abolished in order to speed up resolution of complaints. Additionally,
the NHS and social care complaints systems were integrated for
the first time.
11. The Committee has heard evidence that the new
approach to complaints in the NHS is an improvement on the previous
system, which had been seen as taking too long to achieve resolution
for patients. The Ombudsman told the Committee:
I believe very strongly that the new system is well
designed and has the potential to produce quicker, simpler, better
outcomes and better feedback than anything in place before now.
12. In their written evidence to the Committee, the
providers of complaints advocacy services have stated that:
Satisfaction with the outcome of local resolution
has increased over the last four years, with over 70% of clients
happy with the outcome in 2009/2010 compared to 45 -56% in 2006/2007.
Committee welcomes the improving level of satisfaction with the
local resolution process for complaints, but finds that the Government
can still do more to improve patient experience of the complaints
14. Despite improving satisfaction with local resolution,
the Committee has heard evidence that full implementation of the
new complaints system has not yet been achieved. Mrs. Hazeldine
] it is soul-destroying to follow the current
complaints system that we have, I feel. It may be a very good
system, but it is only as good as the hospital that is implementing
it. If they are not following their own systems, it is incredibly
difficult for a lay person to then challenge them.
15. Mrs. Hazeldine's experience is unfortunately
not unique. Complaints advocacy services are independent of the
NHS and support people throughout England who wish to make complaints
about NHS organisations. Their view of the implementation of the
new complaints system is clear:
The experience of our advocates is that early adopter
Trusts, all of whom received considerable additional support to
introduce the new system, have made significant improvements.
Many other Trusts still lag behind and continue to frustrate people
who want only to be heard and for Trusts to learn from their experiences.
The lesson is that the new system has much to commend it - but
too many organisations cannot or will not implement it properly
without support and oversight.
Committee is clear that the current two-stage model of the complaints
system has the potential to give speedy resolution of, and earlier
learning from, complaints. However, there is still a considerable
amount of work to do in order to fully implement the system throughout
Committee takes the view that the two year period since implementation
of the new system should give the Government sufficient data to
undertake a review and to make improvements. The Committee endeavours
to support this process with this report.
18. The first step in the NHS complaints system is
termed the "local resolution" stage. This entails the
individual complainant raising their complaint directly with the
individual practitioner, with the NHS organisation concerned,
the commissioner of the service or with the organisation's complaints
manager. Most complaints in the NHS are resolved in this manner
and financial compensation is not ordinarily available in locally-resolved
cases. Complaints are normally made in writing, and if made orally,
are to be logged in writing by the person taking the complaint.
Complainants should expect an efficient and effective investigation
and a timely response.
Responses usually come in the form of a report which details how
the complaint was considered, conclusions and remedial actions
(or "action plan"). The complaints regulations were
clarified in 2010 to ensure that complaints made orally and not
resolved within one working day are logged formally as complaints.
19. Those complaints that are not resolved at this
stage can be referred by the complainant to the Health Service
Ombudsman. The Ombudsman can investigate all aspects of NHS care
including failures in service by the NHS or maladministration
by or on behalf of an NHS body. Complaints about the performance
or fitness to practice of individual practitioners can also be
referred to their relevant professional body e.g. the General
Medical Council or the Nursing and Midwifery Council.
20. Prior to the introduction of the new complaints
system, the number of complaints received about the NHS was growing
at a somewhat steady rate of 1.1% per year. The total volume of
complaints was standing at 89,139 in 2008-09 and there had been
a significant (11%) increase seen in complaints about general
practice and dental health services.
2009-10 was the first full year of operation of the new NHS complaints
system; in that year complaints rose by 13.4%, to 101,077, the
biggest annual rise since 1997-98,
with an increase in general practice and dental health services
complaints of 4.4%.
21. In written evidence the Ombudsman told the Committee:
The increase in written complaints [
not come as a surprise. The Local Authority Social Services and
National Health Service Complaints (England) Regulations 2009,
which came into effect on 1 April 2009, imposed stricter requirements
for recording NHS complaints.
22. The Committee is mindful that the rising numbers
of complaints is not just an NHS phenomenon. We have heard evidence
that complaints to the Financial Ombudsman have risen by 119%
in the last year, that the Housing Ombudsman has seen a 43% increase
in complaints and that the Press Complaints Commission reported
a 7-fold increase in annual complaints.
written evidence to
the Committee, the recent rise in complaints about the NHS has
been variously attributed to the 28% rise in demand for healthcare
over the last ten years,
greater consumer awareness of the complaints process
and also a deterioration in the standard of care delivered
by the NHS. The Committee
has also heard that:
It is difficult to say whether there has been a deterioration
in care as a whole.
24. Additionally, organisations that are proactive
on their complaints policy and see complaints as useful intelligence
on patient satisfaction will often encourage more complaints and
consequently have higher complaints figures. The
NHS complaints statistics show an increase of 13.4% in complaints
between 2008-09 and 2009-10. This is comparison of data between
two distinct complaints systems is unreliable. Furthermore, the
growing number of people treated by the NHS, the stricter reporting
arrangements, more information about how to complain and a general
improvement in consumer rights awareness may have added to the
volume of complaints that the NHS receives.
25. In the course of this inquiry, the Committee
has heard numerous stories in oral and written evidence of significant
failures in NHS care and treatment. The Committee does not seek
to pass judgement on the standard of care in the NHS in this report.
Rather, we are struck by the volume, variety and complexity of
complaints that are received in the NHS on a daily basis. In
particular we are concerned about the number of individual cases
where complainants did not feel the NHS was sufficiently responsive
to their concerns. It is in this variable individual experience,
rather than in movements in the headline totals, that the Committee
feels that there is a real issue which the NHS needs to address.
26. Complaints undergo a process of grading, generally
though not universally at the beginning of the process. "Traffic-lighting"
or grading complaints is used to support the effective assessment
of the risks associated with the complaint i.e. the likelihood
of it recurring and its consequences for the patient, and the
consequences for the organisation such as likelihood of litigation,
likely costs incurred and potential for adverse media interest.
Grading can also support prioritisation of complaints and can
indicate the type of investigation that is required in order to
resolve it, though the evidence from individual patients to the
Committee suggests that this is not always the case.
27. Broadly speaking, complaints fall into two distinct
categories; customer service-type complaints, relating to the
non-clinical aspects of care including how clinicians interact
with patients, and those complaints relating to clinical care
which are by nature more serious in terms of their potential outcome
for the patient. Clearly, these complaints need to be handled
in a very different manner.
service complaints often can and should be resolved immediately
by the person receiving the complaint apologising and rectifying
the issue, be they a clinician, a PALS officer or any other employee
of the NHS. Due to the nature of these types of complaints, admitting
that there was a problem, dealing with it and apologising will
save time and resources that can be diverted to prompt and effective
investigation and resolution of more serious and complex cases.
29. The Minister of State for Health, Simon Burns,
acknowledged that complaints need to be resolved more quickly:
Also, again from being a constituency MP rather than
a Minister, there can sometimes be frustration at the length of
time it might take to investigate and come to a conclusion on
a complaint that has been made at a local level.
30. It was suggested to the Committee that in order
to resolve complaints more speedily there may well be a case for
two separate "channels" within the complaints system.
The Minister stated that:
] one could say yes, in principle, but I fully
take on board the rather practical point you are making: whether
it would be more effective, efficient and sensible to have a twochannel
system or where serious clinical and medical decision complaints
are treated in one tier and the example you give of food and things
that are important to peoplebut, in the run of things,
may not be considered as critical as where there has been a significant
failure in carein the same tier so that it clogs up the
whole system rather than prioritising them in different channels.
will always be difficult for a single complaints system to manage
complaints about the great diversity of issues that occur on a
daily basis. In its review of the complaints system in England,
the Government should consider carefully the development of separate
systems for investigation and resolution of customer care complaints
and more serious complaints about clinical issues. A stratified
set of standards relating to each part of the system should also
Reviews of serious untoward incidents
32. Incident reporting is the mechanism through which
staff raise issues or concerns with senior managers, and is a
routine aspect of all clinical care in the NHS. Staff are required
to report any incident across a broad range of categories, from
threats of, or actual violence from patients though to unsafe
Staff will generally complete a paper-based form and bring this
to the attention of their manager immediately.
33. Organisations use different terminology to describe
very serious incidents, such as critical incidents or serious
crucial incidents, but the common terminology is serious untoward
incidents. A serious untoward incident (SUI) is an unexpected
event that has the potential to:
]cause serious harm, and/or likely to attract
public and media interest that occurs on NHS premises or in the
provision of an NHS or a commissioned service. This may be because
it involves a large number of patients, there is a question of
poor clinical or management judgement, a service has failed, a
patient has died under unusual circumstances, or there is the
perception that any of these has occurred. SUIs are not exclusively
clinical issues, an electrical failure for example may have consequences
that make it an SUI.
34. Such incidents are reported and investigated,
commonly using the Root Cause Analysis framework, so that lessons
can be learned and recurrence can be minimised or prevented, and
patient complaints can also be registered as an SUI. In written
evidence to the Committee, Sands (the stillbirth and neonatal
death charity) brought the case of Baby L, who died in 2009, to
our attention. Baby L's parents stated that:
We felt that if we went through the complaints procedure
we just weren't going to get anywhere. The hospital has been so
obstructive and unhelpful. We have no faith in them at all.
35. Sands went on to state that:
On L's anniversary a year later parents requested
a third meeting with the hospital . At this meeting they were
informed that a Serious Untoward Incident report had been conducted
eight days after L had died which answered some of the questions
they had been asking the Trust for months, but also conflicted
with their version of events. They were not asked for their input
or informed that an SUI was being conducted at the time.
Committee recommends that in all cases where serious untoward
incidents are being investigated, whether or not a complaint has
been made, those directly affected should always be included as
full participants in the process.
Investigation by the Ombudsman
37. The second and final stage of the NHS complaints
system (complaining to the Health Service Ombudsman) is normally
instigated only when the local resolution stage has been completed.
The Ombudsman undertakes independent investigations into complaints
about NHS funded care and treatment brought to that office by
complainants or their relatives. According to the Health Service
Commissioners Act 1993 complaints may be made to the Ombudsman
on the grounds of maladministration and/or poor service.
This being the case, a further two tests are applied before the
Ombudsman accepts a complaint for formal investigation or intervention.
Firstly, a person must have suffered injustice or hardship as
a result of the poor service or maladministration, and secondly
there must be the prospect of "a worthwhile outcome".
38. The Ombudsman has noted a significant increase
in complaints proceeding to stage two of the complaints system.
In 2009-10 complaints to the Ombudsman more than doubled on the
previous yeara total 15,579 complaints were closed in that
Just over a half of these complaints (9,011) were closed as they
had not completed the local resolution stage.
The Ombudsman told us that:
Closing these complaints often involves engaging
with the NHS body in question and can result in that body carrying
out additional work or simply expediting the complaint.
39. A further 1,373 complaints were withdrawn by
the complainant at this stage. The remaining complaints were looked
at in detail in order to decide if a full investigation was warranted.
This involved the Ombudsman calling for more information from
the body being complained about, reviewing papers or taking professional
advice, and some complaints were resolved without the need for
In 4,210 cases complaints were examined and it was found that
there was no evidence of maladministration or unremedied injustice,
or that the outcome sought by the complainant e.g. disciplinary
action against a clinician, was not achievable.
40. The Ombudsman told the Committee that many people
are satisfied with the service provided by that office:
] 90% of people whose complaints we investigated
were satisfied with our service overall. 70% of people whose complaints
we didn't investigate were happy with our service. The figures
and the numbers are there for the Committee if you want to look
41. Despite these positive statistics, the Committee
has heard significant concerns from patients and patient representatives
about the numbers of cases accepted for investigation:
Our biggest concern about the Ombudsman is that [
they take very, very small numbers of complainants, either as
official investigations or what they describe as intervention
where they don't investigate a complaint but they will contact
the trust. Combined, it is something like 2% to 3% of those people
that take their complaint to the Ombudsman. So we are talking
about thousands of people who have, for whatever reason, felt
that the response they received locally was not adequate, who
do not receive any kind of independent scrutiny of that response.
In 98% of cases the Ombudsman doesn't investigate98%.
Less than 1.5% are ever investigated and this service costs us
£34 million per annum. It's wrong.
Action against Medical Accidents also expressed some
concerns about the numbers of complaints being independently investigated:
Bearing in mind that the Healthcare Commission had
dealt with 7,827 independent reviews in 2007-2008 these figures
would suggest that many people are being 'bounced' back to attempt
further local resolution with the NHS body they are complaining
about. Whilst we accept that in some circumstances this might
be appropriate, we are worried that in others it is not.
42. In her evidence the Ombudsman reported that her
department does a significant amount of informal work on improving
complaints handling in the NHS, including informal measures to
support resolution and in supporting people to make their complaints
to the right organisation at the right time. Although only 3%
of the complaints received by the Ombudsman were accepted for
formal investigation or intervention,
the evidence shows that a considerable minority of well-made complaints
were unofficially examined by the Ombudsman.
43. A majority of the complaints brought to the Ombudsman
each year are incorrectly made or have not been though local resolution.
The small number of cases accepted for formal investigation and
intervention each year disguises the fact that a considerable
amount of informal investigation takes place.
44. As previously mentioned, the final test applied
to whether a complaint is accepted for investigation by the Ombudsman
is that a "worthwhile outcome" could be achieved.
45. The Ombudsman told us that:
] the final one [test] is about whether we
could get what we would describe as a worthwhile outcome. Hopefully,
we would use more sensitive language than that when writing to
46. It is the point about a "worthwhile outcome"
that has arisen time and again during the inquiry. Several complainants
and organisations have told us that this terminology is often
used in letters to them, telling them that their case has been
closed by the Ombudsman:
In fact, they tactfully ignored any recommendation
that would benefit me, [
] this was reinforced through the
ineffective intervention by the Parliamentary, Health Care Ombudsman,
wasting years of my time to achieve nothing but a 'not worthwhile
In February 2010 the Ombudsman declined to investigate
because missing medical records meant the family were unlikely
to get a 'worthwhile' response.
] Case has been refused by PHSO for an investigation
as "no Worthwhile Outcome" can be identified
'6 months reconsideration'
47. Although the Committee has heard that the Ombudsman
will generally only accept complaints that have progressed through
the "local resolution" stage of the process, some flexibility
does exist within this. The Ombudsman told us that:
] we have to say, "Unless something extraordinary
is going on here, we think the NHS body should have the opportunity
to look at this first."
recommend that the Ombudsman urgently reviews the manner in which
data on complaint handling by her office is communicated to the
public as she appears to be significantly more actively engaged
in reviewing NHS complaints than is obvious from the published
terminology "no worthwhile outcome" which arises from
the Health Service Commissioners Act is being used in communication
with complainants. Several have told us that their complaints
were rejected because "no worthwhile outcome" could
be achieved. The Committee recommends that the Ombudsman urgently
reviews the use of this terminology in correspondence as it appears
significantly to undermine public confidence in the complaints
people see the role of the Ombudsman as a general appeals process
for the complaints system, but the remit under the Health Service
Commissioners Act is much narrower than that. The Committee is
of the view that a complainant whose complaint is rejected by
the service provider should be able to seek independent review.
The legal and operational framework of the Ombudsman's office
should be reviewed to make it effective for this wider purpose.
3 The Health Service Ombudsman, Making Things Better,
(London 2005) Back
Department of Health, Committee of Inquiry to investigate
how the NHS handled allegations about the performance and conduct
of Richard Neale, Cm 6315, August 2004 Back
Department of Health, Committee of Inquiry into how the NHS
handled allegations about the conduct of Clifford Ayling,
Cm 6298, July 2004 Back
The Department of Health, The NHS Constitution, March 2010 Back
The Health Service Ombudsman, Making Things Better, 2005 Back
Q 73 Back
Ev 107 Back
Q 49 Back
Ev 107 Back
Local Authority Social Services and National Health Service Complaints
(England) 2009 (SI 009/302) Back
The Department of Health, Clarification of the Complaints
Regulations, January 2010 Back
The Information Centre for Health and Social Care, Data on
written complaints in the NHS 2008-2009, November 2009 Back
The Information Centre for Health and Social Care, Data on
written complaints in the NHS 2009-10, August 2010 Back
Ev 146 Back
Ev 142 Back
Ev 80 Back
Ev 153 Back
Q 5 Back
For example, NHS Healthcare Workforce website, NHS Bolton and
NHS Stockport Complaints Policies Back
Q 361 Back
Q 391 Back
For example, see NHS Surrey, Incident Reporting Policy, March
For example, see NHS London, Serious Untoward Incident Reporting
Guidance, October 2007 Back
CAL 38 Back
Health Service Commissioners Act 1993, Section 3 Back
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review of complaint handling in the NHS in England 2009-10, October
Ev 161 Back
Q 90 Back
Q 8 Back
Q 55 Back
Ev 16 Back
Ev 149 Back
Q 96 Back
CAL 46 Back
CAL 38 Back
Ev 87 Back
Q 79 Back